overview of selected primary health care models · overview of selected primary health care models...

Overview of Selected

Primary Health Care Models

July 2004

A Background Document to the Final Report –Building A Primary Health Care Infrastructure

in Halton-Peel: Planning for the Future

(April 2004)

#600 – 6711 Mississauga Road Telephone: (905) 814-5995 Mississauga, ON L5N 2W3 Toll Free: (888) 452-6818 [email protected] Fax: (905) 814-4835

www.hpdhc.com

Overview of

Selected Primary Health Care Models

July 2004

A Background document to the Final Report – Building A Primary Health Care Infrastructure in Halton-Peel:

Planning for the Future (April 2004)

-Peel: Planning for the Future (April 2004)

Prepared byRose Cook, Senior Health Planner

Elaine Kachala, Health Planner

#600 – 6711 Mississauga Road Telephone: (905) 814-5995 Mississauga, ON L5N 2W3 Toll Free: (888) 452-6818 [email protected] Fax: (905) 814-4835

www.hpdhc.com

Table of Contents Executive Summary ................................................................ 4 1. Introduction ....................................................................... 6 2. Definitions of Primary Health Care................................... 7 3. International Experiences with Primary Health Care

Reforms ............................................................................ 9 3.1 The Allure of Reform: Primary Health Care and Evidence ..................9 3.2 An Overview of Selected International Models ................................10

3.2.1 The Models .....................................................................10 3.2.2 Common Organizational and Policy Design Elements Primary

Health Care ...................................................................13 4. An Overview of Canadian Models ................................... 16 5. Notable Model Features .................................................. 18

5. 1 Different Models...........................................................................18

5.1.1 Professional Primary Health Care Models............................19 5.1.2 Community Primary Health Care Models.............................20

6. Obstacles and Barriers to Reform ................................... 23 7. Facilitators of Successful Reform .................................... 25

8. Conclusion ....................................................................... 26 References

Appendix A Definitions of Primary Health Care

Overview of Selected Primary Health Care Models 2004 July 2004

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Executive Summary The Halton-Peel District Health Council (HPDHC) has a mandate to assist and provide the Minister of Health and Long-Term Care and other decision-makers with health system planning information and advice about the health needs of the residents of Halton and Peel and the resources required in the health system to meet them. Based on knowledge of Ministry policy and direction, local provider capacity and local health needs, the HPDHC works in partnership with government, local providers and the local population to develop this information and advice leading to solutions-oriented planning and a strengthened and enhanced health care system. In keeping with the HPDHC’s mandate and recognizing the international, national and provincial focus on building strong primary health care systems as a means to improving population health and health care system integration, the Halton-Peel District Health Council established a Primary Health Care Task Force in April 2003. The role of the Task Force was to oversee a primary health care planning project that would provide information to the Minister of Health and Long-Term Care, the Ontario Family Health Network (OFHN) and other decision-makers about the current environment of primary health care in Halton-Peel, as well as advice and recommendations on directions for successful primary health care reforms. The key messages, advice and recommendations emerging from this project were based on an extensive consultative and data collection process and may be found in the final report entitled Building a Primary Health Care Infrastructure in Halton-Peel Planning for the Future (April 2004). This report is one of three background documents to the final report. It provides a more detailed analysis of the literature review of primary health care models in other jurisdictions. On April 2003, a Literature Review Subcommittee was formed by the Halton-Peel Primary Health Care Task Force to conduct a literature review of primary health care models in other jurisdictions, identify best practices and consider how reform experiences could inform directions in Halton-Peel and Ontario. Given the breadth and scope of reforms internationally, the most manageable approach was to utilize findings from existing syntheses and analyses of models. A key finding from this review is that organizations in health systems, the politics, the models and the terminology used to describe their components, as well as the basic conditions in different countries vary so significantly that it is extremely challenging to make comparisons in terms of an assessment of what works well, or even to identify specific elements for examination. Without these details, it is difficult to identify particular models as ‘best practice’. However, it is possible to identify best practice trends in terms of common or essential policy and organizational design elements of reform, the facilitators and barriers of reform and implications and recommendations from other experiences. This literature review was a vital component of this project in terms of highlighting best practice


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trends and alerting the Task Force to the reality of reform, including how to avoid potential roadblocks as ideas generate momentum in Halton-Peel. It also highlighted some cautions when using evidence in primary health care decision-making, recognizing that many initiatives have not been evaluated, that some evidence is contradictory and specific initiatives across different locations can have different results.

Key Messages from the Literature Review Process:

There is no single best model of primary health care that can produce all of the desired effects of primary health care (effectiveness, productivity, accessibility, equity of access, continuity, quality, responsiveness). International experience suggests that a blending of models/approaches is required to meet diverse community needs and interests and provider practice style preferences.

Understanding the nature and pace of primary health care reform is key to developing appropriate strategies.

Essential policy and organizational design elements are emerging internationally which serve to strengthen primary health care. These elements reflect best practice trends, which may be incorporated in primary health care reforms locally, but require research and ongoing evaluation, as conditions are likely to vary across locations.

The obstacles or barriers to reform in other countries are not different from Canadian experiences. Key barriers or obstacles to local reform include: a) lack of political commitment and leadership, and insufficient policy continuity as a result; b) temptation by government to micro-manage; c) powerful interest groups within and outside the health system who are resistant to change; d) failure to integrate primary health care into the overall health and social systems; e) unrealistic objectives and expectations; and f) failure to adopt a change strategy that matches the local environment and combines top-down policy directives with bottom-up direction.

Ten key facilitators of successful reform include: 1. Clear direction and commitment by government that is supported in several ways including:

a) clearly defined milestones with longer-term objectives, b) incremental steps, c) acknowledgment of change potential, d) change management support, e) reasonable timeframes for implementation (e.g., 1-2 years), f) the widest possible stakeholder commitment to new solutions coupled with autonomy that allows stakeholders to influence the system and facilitate continuity and sustainability, and g) ongoing evaluation.

2. Tolerance for pluralism by government in terms of respect for, and allowance of, a variety models or approaches, including those that fall outside the desired framework.

3. Targeted and adequate funding to support change. 4. Physician support, but not necessarily all at the beginning. 5. Administrative simplicity. 6. Collaborative education, skill development and practice that are focused on shared-care,

inter/multidisciplinary teams of health professionals and intersectoral approaches, leading to greater integration and patient benefits.

7. Government initiatives to develop national standards regarding the terminology and scope of practice for nurses and other non-physician health providers.

8. Electronic health information systems/technology to establish connectivity among providers along the continuum of care.

9. Public education and involvement in reforms. 10. Development of community capacity and involvement through leadership development and

devolving authority.


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1.0 Introduction In April 2003, a Literature Review Subcommittee was formed by the Halton-Peel Primary Health Care Task Force to conduct a literature review of primary health care models in other jurisdictions, identify best practices and consider how reform experiences could inform directions in Halton-Peel and Ontario. Given the breadth and scope of reforms internationally, the approach taken in this review was to utilize findings from an array of existing syntheses and analyses of models; specifically, focusing on essential or common organizational and policy elements of reform, facilitators, motivators, barriers, implications and recommendations for reform. Section 2 begins the report with a definition of primary health care that was endorsed by the Primary Health Care Task Force. Section 3 provides an overview of selected international primary health care models looking at key design features, common organizational and policy elements that appear to be emerging in most countries. Section 4 provides an overview of Canadian models. Section 5 summarizes notable model features based on a taxonomy of primary health care models that was conducted by the Canadian Health Services Research Foundation (September 2003). Section 6 summarizes the major obstacles and barriers to successful reform. Section 7 reviews facilitators for successful reform. Section 8 provides a conclusion and summarizes future directions with the most potential for success. Listed below are the key documents that were reviewed for this paper.

Choices for Change: The Path for Restructuring Primary Healthcare Services in Canada, Canadian Health Services Research Foundation (CHSRF), 2003. This report provided a taxonomy of organizational models, an evaluation and ranking of the outcomes associated with the models based on several desired effects that primary health care should produce, and a ranking of the models.

Health Care in Canada. The Canadian Institute for Health Information, 2003. This report included a brief overview of Canadian models focusing on organizations where different providers work together.

Sharing The Learning – The Health Transition Fund Synthesis Series: Primary Health Care. Ann L. Mable and John Marriott, Minister of Public Works and Government Services Canada, 2002. This report provided a synthesis and analysis of reforms including implications and recommendations for reform based on experiences internationally.

Report to the Health Transition Fund on the Evaluation of Primary Care Reform in Ontario. PriceWaterhouseCoopers, March 31, 2001. This report summarized some of the main aspects of reform including principle findings with respect to facilitators and barriers to reform.

Opportunities and Potential – a Review of International Literature on Primary Heath Care Reformand Models. Prepared for Health Human Resource Strategies Division, Health Policy andCommunications Branch Health Canada. Prepared by, John Marriott and Ann L. Mable, Minister ofPublic Works and Government Services Canada, August 2000. This report provided a synthesis andan analysis of reforms internationally including an overview of essential organizational and policyelements in most countries.

Primary Health Care: A Framework for Strategic Directions. Prepared by the World Health Organization (Updated Draft) (October 2003), this report reviewed changes in primary health care over the past 25 years. It highlights future directions in light of limitations of reforms to date.


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2.0 Definitions of Primary Health Care There are variations in how the terms ‘primary care’ and ‘primary health care’ are used. Primary care typically includes the diagnosis, treatment and management of health problems, with services delivered by physicians. Primary health care incorporates primary care, but also recognizes and addresses the broader determinants of health including population health, sickness prevention and health promotion, with services provided by physicians and other professionals in partnership and often in multi-disciplinary teams (Marriot & Mable, 2000). There are many definitions available for primary health care. Three commonly cited definitions in Ontario include the World Health Organization (1978), the Health Services Restructuring Commission (1999) and Barbara Starfield (1998). Appendix A of this report contains these definitions. Listed below are key concepts that are integral to all of these definitions that underpin the current thrust of reforms and form the basis of the Halton-Peel DHC’s report on primary health care. Key Concepts Of Primary Health Care:

First level of care; the first point of contact that people have with the health system

24/7 response so that services are available when a need arises Patient–provider relationship based on established trust and knowledge of the

patient and his/her family Person-oriented on-going care over time Universally accessible care, that is close to home/work Economically affordable and sustainable care for individuals, communities and

the country Based on sound and socially acceptable methods, including knowledge about

families, communities and cultures of the population served Includes a range of essential services that promote and preserve health and

provide care for illness and disability Integral to the health system; it is a gateway to secondary & tertiary care

through its coordinating role Facilitates care coordination across providers and systems to address the

broader determinants of health Provided by a broad range of professionals working in partnership and/or

teams Involves citizens in health care decision-making

The most commonly accepted description of primary health care functions is the list identified by the Provincial Coordinating Committee on Community and Academic Health Science Centre Relations (PCCCAR, 1996). The Ministry of Health and Long-Term Care


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(MOHLTC), the College of Family Physicians of Canada (CFPC), the Ontario College of Family Physicians (OCFP) and the Ontario Medical Association (OMA) have acknowledged this core list. This list was also endorsed by the Primary Health Care Task Force. The core services defined by PCCCAR are:

1. Health assessment 2. Clinical evidenced-based illness prevention and health promotion 3. Appropriate interventions for episodic illness and injury 4. Primary reproductive care 5. Early detection, initial and ongoing treatment of chronic illnesses 6. Care for the majority of illnesses (in conjunction with specialists as

needed) 7. Education and support for self-care 8. Support for in-home, long-term care facility and hospital care 9. Arrangements for 24 hour/7 day a week response 10. Service coordination and referral 11. Maintenance of a comprehensive client health record for each

rostered consumer in the primary health care agency 12. Advocacy 13. Primary mental health care, including psychosocial counseling 14. Coordination and access to rehabilitation 15. Support for people with a terminal illness


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3.0 International Experiences with Primary Healthcare Reform 3.1 The Allure of Reform: Primary Health Care and Evidence Reforming the delivery of primary health care is a concern that spans the globe. Jurisdictions in all corners of the world are implementing new models for the delivery of primary health care services. This heightened focus on reform is rooted in two key themes:

i. Evidence indicates that countries with strong primary health care infrastructures (Starfield, 1998; Macinko, Starfield & Shi, 2001, 2003): Can reduce socioeconomic disparities in health, Have better health status; and Spend less on health care.

ii. Primary health care is recognized as the cornerstone of an effective and integrated

health system because of its role as a “multisystem connector” (HSRC, 1999a, 1999b, 2000) and its function as a “gateway to secondary and tertiary care through its coordinating/connector role”(Starfield, 1998).

While international research and reviews provide sufficient confidence on which to base policy recommendations for primary health care, some problems still exist (WHO, 2003). In Canada, the Royal Commission on the Future of Health Care (Romanow Commission, 2002) studied the health care system intensely and recognized primary health care reform as the most important area for change indicating that “there is almost universal agreement that no other intuitive holds as much potential for improving health and sustaining our health system.” The Commission recommended a number of ways to rebuild primary healthcare. However, it also noted “some aspects of primary health approaches are not necessarily grounded in research and evidence, but rather appear to be based on good ideas and preferences.” The Commission also noted that in some cases there is “insufficient and even contradictory evidence on important characteristics of primary health care.” Hutchison et al observed that “systematic policy-informing evaluation of primary care innovations in Canada, including those that have been in existence for several decades are remarkably limited, often narrowly focused and not readily generalizable.” (Hutchison et al., 2001). Recognizing the potential of primary health care and the limitations of the evidence thus far, there is a need to continually review experiences, learn from others, implement change and then evaluate the local changes made. The following sections include summaries from the review of international research.


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3.2 An Overview of Selected International Models

This section summarizes key design aspects of primary health care models in selected countries, as well as common organizational and policy elements of primary health care that are be emerging in many countries. This summary is based on Marriott and Mable’s Review of International Literature on Primary Health Care Reform and Models (2000) and their presentation on comparing and contrasting primary health care reform (Mable and Marriott 2003).

3.2.1 The Models

United Kingdom Evolution from general practitioner (GP) Fund holders to Primary Care Groups (PCG)

to Primary Care Trusts (PCT) (England) Consolidation, refocusing roles from Regional Health Authorities (RHA) to Strategic

Health Authorities PCTs responsible for primary health care (PHC) PCTs assume responsibility for all health services (for a defined pop)

− PHC and some community services − Commission (contracts with) all other specialists and hospital services

Generous fund holding budgets (including health care organization costs for computers, employees, building improvements and drug costs)

PCGs and PCTs have the flexibility to move funds around between categories; surpluses are kept with set rules governing their use

Sicker patients not discriminated against Decreased drug costs and wait times Increased administration costs; significant start up time required Health promotion is increased Communication improved

New Zealand

Primary Care Organizations (PCOs) & some fee-for-service (F.F.S.) practices The majority of GPs have moved into PCOs PCOs are roster-based and funded through weighted capitation with some fund

holding (e.g., drugs, diagnostics) There are two kinds of PCOs: GP-led and Community-owned (tend to be not-for-profit

with a focus on underprivileged populations) Single Health Authority contracts and funds all services for PCOs A major disadvantage is the absence of universal coverage which is having a negative

impact on access: PHC services for adults over 16 are not covered; citizens over a certain income pay all costs; government subsidies are paid to GPs and practices for children and for adults with Community Service Cards (CSCs are provided to citizens with low incomes) and High Use Health Cards (HUHCs are provided to those with chronic conditions)

All PCOs have established information systems


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The Netherlands

Sickness Fund Organizations (SFO) are vertically integrated not-for-profit organizations that plan, manage and purchase all required services from providers including primary health care

The majority of the population is enrolled with SFOs, with the remaining higher income population covered by higher insurance. Citizens roster with the SFO of their choice

Services are provided through contracts with predominately independent family physician (FP) groups

− Rosters average 2300 per physician − Gate keeping to specialists is maintained (e.g. patients do not have free

access) − FPs are funded through capitation (plus some F.F.S. for higher incomes with

private insurance) − FPs are required to be available 24 hours a day, 7days a week − FPs receive additional funding in a number of areas (e.g., incentive payments

to treat target populations such as diabetes; continuing education; pharmaco-therapeutic meetings)

Lower referral rates and hospital utilization, and increased use of electronic health records

7% of the population is served by Health Centres, which are cooperative associations with multidisciplinary providers

Finland

Municipalities are regionally integrated organizations that plan, manage and fund primary health care, specialized and hospital care (they may also provide their own primary health care)

Services are provided predominately through municipally owned Health Centres (not single sites or locations: a number of services together may form Health Centre operations) and by interdisciplinary salaried providers at multiple sites

A ‘Personal Physician Program’ that rosters clients, has voluntary participation and blended remuneration. Introduced in 1990s, the focus is on improving access and shortened wait time

User charges are applied Australia

Stands out as having little fundamental change No intermediary integrated organization Most primary health care services are by small or solo general practitioner (GP)

practices with the capacity to charge more than Medicare pays Some multidisciplinary Health Centres exist plus rural and remote programs The recently established Divisions of General Practice – geographically-based

organizations conceived for and developed by GPs may move more physicians into groups


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United States

Primary health care is a highly complex environment with services that take on many forms, relationships and organizational models depending on geography, relative market penetration of managed care, population density and other factors – major players are Health Maintenance Organizations (HMOs) (these too vary widely), and Health Centres for special groups

There is a trend towards group/networked practices Primary health care providers are mostly physicians Major challenges still include rising costs and large numbers of people without

coverage of any kind


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3.2.3 Common Organizational and Policy Design Elements of Primary Health Care There are many lessons to be learned from primary healthcare reform efforts in other jurisdictions. “Although organizations in health systems and primary health care varies in design by country, particularly policy and design direction, it is possible to discern with some confidence, essential elements that are emerging with consistency across models internationally which serve to strengthen primary health care” (Marriot & Mable, 2000). These essential elements are detailed below. Service and population health approach A population health approach is at the core of primary health care. “It aims to improve the health of the entire population and to reduce health inequities among population groups. In order to reach these objectives, this approach looks at and acts upon the broad range of factors and conditions (or determinants) that have a strong influence on our health (Health Canada, 2001)”. Primary health care strives to address health in terms of the sometimes complex interrelationships between determinants, sometimes with cross-sectoral implications, an approach that requires a broad perspective and partnerships both within and outside the health care system. In that regard, access to primary healthcare services usually involves comprehensive core services including health promotion and sickness prevention, diagnosis and treatment, urgent care, 24/7 coverage, and management of chronic illness. Multi-disciplinary team approach to care Multi-disciplinary efforts in the way of teams (including physicians, nurses, dieticians, social workers, physiotherapists and other providers) and collaborative practice are apparent in most of the jurisdictions, with special emphasis on the intermediary organizations as the organizer or coordinator of services. The potential to extend the notion of multidisciplinary services beyond the primary healthcare sector is enhanced by the broader scope of the intermediary organizations. Physicians are working more in groups Physicians are working more in groups to create an environment that has the potential for work sharing to address increasing burnout among physicians with no “backup” support; for a collegial environment to support information exchange; and, to enhance the quality and safety of patients and family physicians alike. Funding changes One of the main underpinnings of many primary healthcare reform initiatives is to change the basis of physician payment. The main goal in this change is to move away from payment which is based on the volume of services to an approach that is more patient-centered, focuses on preventative actions, and ensure care flexibility (i.e., utilizing multi-disciplinary teams). Capitation is one example and it is present in all countries (except Australia), as funding to the intermediary organizations and/or to the GPs/primary health care organizations.


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Funding changes also aim to provide a greater range of funding models to address the need for health care system sustainability, diverse practice preferences and quality of life issues for physicians. Citizen choice Increasingly there is a trend towards citizen participation in governance, management and planning. Health improvements are sought through the involvement and participation of patients and communities. Citizen choice represents an important policy element as is supported in most jurisdictions in terms of choice of organization and provider.

Patient enrollment/rostering Rostering or registration refers to the formal process of creating a list of citizens/patients who are formally linked to, or enrolled with, an organization or provider. The process usually encompasses both the right (or responsibility) of individuals to exercise some freedom to choose (or select) their organization or provider and the identification of those individuals on a formal roster. It is this roster that forms or establishes the population serviced by the organization or provider. Rostering may form part of the intermediary organization and/or the primary healthcare/ GP component, is present or emerging in all countries except Australia. Information systems/technology Information technology (IT) is a key component in ensuring the capacity of a reformed primary healthcare system. From a client-perspective, effective IT can enable enhanced access and linkages with other healthcare providers. Fundamental health information systems including electronic health records are considered an important priority in all of the jurisdictions. From a systems-perspective, reliable and usable data will facilitate evidence-based planning at the local, regional and provincial level. Vertically integrated intermediary organizations In most of the countries primary health care is linked to, or expressed within, vertically integrated intermediary organizations, which are positioned between the central government and the primary health care sector they are responsible for. For the most part, the countries profiled did not make radical fundamental changes to their systems overall, but reorganized and redirected resources often on a systemic level, in ways to focus on and support primary health care and its providers. Focus on quality Quality is an important policy objective in all jurisdictions and for the health professions. It includes continuing medical education, accreditation, planning/evaluation, information system development, special training particularly for rural areas, re-certification in some jurisdictions, incentives for preventative care, use of disease management approaches, access to health information and decision making information, and the formation of group practice and multi-disciplinary team.


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In addition to top-down, government directed models; locally designed approaches can be a viable step towards integration. Integration experience suggests that communities can achieve integration at a micro level if appropriate supports are put in place (HSRC, 2000). In Ontario, linking FHNs, FHGs, HSOs and CHCs and defining locally appropriate multidisciplinary solutions to improve the practice environment can facilitate integration (OCFP, June 2003). As well, physicians in Toronto have expressed interest in having flexibility for different models of care provision to expand service for their patients (TDHC, 1999).


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4.0 An Overview of Canadian Models This overview is based on a summary of selected primary health care sites across Canada, focusing on organizations where different primary health care providers work together. It is based on work conducted by the Canadian Institute for Health Information (CIHI, 2003).

Newfoundland/Labrador Primary Health Care (PHC) Networks; Community Health

Centers; PHC Framework and Implementation Plan (Sept. 2003).

Prince Edward Island Family Health Centres (FHCs); Community Health Centers

(CHCs); multidisciplinary teams; collaborative practice. Nova Scotia Primary Health Care (PHC) Organizations; Nurse

Practitioner/Family Physician Collaborative Practice; Advisory Committee on Primary Health Care Renewal; Primary Health Care Transition Fund pilots (PHCTF).

New Brunswick Community Health Centers (CHCs) (GP salary, 24/7

access, Registered Nurse expanded role, multidisciplinary); focus on recruitment and retention of nurses and physicians; and TeleCare.

Quebec Family Medicine Groups (teams); CLSCs. Ontario Family Health Networks (FHNs); Family Health Groups

(FHGs); Community Health Centers (CHCs); Health Service Organizations (HSOs); Primary Care Networks; Community Sponsored Contracts; Group Health Centre; Northern Group Funding Plans; Telehealth; PHCTF pilots

Manitoba Community nurse resource centers; Primary Health

Centers; Community Health Centers; Provincial Primary Health Care Network; Regional Health Authorities submit Primary Health Care Operating Plans; Primary Health Care Renewal Group; Winnipeg Integrated Services Initiative; PHCTF pilots.

Saskatchewan Primary health service sites; community clinics; primary

health care teams and networks; Telehealth


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Alberta Community Health Centers (CHCs); telephone triage; Primary Health Care Reform strategy in 2003.

British Columbia PHC organizations; CHCs; PCNs; shared care;

interdisciplinary practice. Territories Community Health Centers; Dept. of Health &, (Yukon Northwest, Nunavut) Social Services is developing an integrated

delivery model to advance primary health care in the in NWT; PHCTF pilots; Telehealth.

While fee-for-service/solo/group practice is still the dominant model across the country, there are many newly emerging models with similar elements that focus on:

Physician movement into groups Multidisciplinary teams Rostering (enrolment) Citizen participation/choice Per-person capitation funding Core services; 24/7 accessibility Information systems/technology Potential for growth towards vertically integrated organizations

(Mable and Marriott, 2003) It is important to acknowledge that change is constantly occurring across Canada. As this document is being written a new model in Ontario is evolving called Family Health Teams, which will see physicians working together with nurses, nurse practitioners and other providers. Similarly, local area networks are developing in Quebec, and other areas across Canada are also experiencing tremendous change. A key aspect of these reforms is to achieve integration through inter/multidisciplinary teams and shared-care (presentations at the Primary Health Care Conference, 2004). A recent draft report by the World Health Organization, titled Primary Health Care: A Framework for Future Strategic Directions (2003) indicated that “Canada’s efforts to combine different health professions in primary healthcare teams seems to be the right way to go. ‘Co-located’ professionals lead to greater integration in the health care system and benefits patients.”


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5.0 Notable Model Features 5.1 Different Models A synthesis of literature on primary health care models in other jurisdictions nationally and internationally indicates that no single best model can produce all of the desired effects of primary health care (effectiveness, productivity, continuity, accessibility, equity of access, responsiveness and quality,)1 (CHSRF, 2003). The Canadian Health Services Research Foundation (CHSRF) indicates that two models may come close to producing several desired effects, based on a ranking of different models. These are the community integration and professional coordination models (CHSRF, 2003). These models are briefly summarized below, based on the CHSRF (CHSRF) paper, Choices for Change: The Path for Restructuring Primary Healthcare Services in Canada (2003). Overall, experience suggests that a blending of models/approaches is required to produce all of the effects and to meet diverse community needs and interests and provider practice style preferences (CHSRF, 2003; Marriot & Mable, 2000). 5.1.1 Professional Primary Healthcare Models There are two professional models of care: the contact model and the coordination model. Professional primary healthcare models are designed to deliver medical services to patients who seek these services or to people who choose to register with one of the parties responsible for primary healthcare to obtain these services. Four features characterize these models: 1) Physicians most often provide care, though nurses may also be included in the care giving team. 2) Care typically is limited to preventative, diagnostic or curative medical services. 3) The responsibility falls to physicians working alone or in groups who do not report to a regional or local healthcare entity. 4) The public plays no role in governance of these organizations and funding is linked to compensation for physicians, primarily by a per capita formula or a mix of payment methods (i.e., per capita, fee for service, and sessional fees).

1 Definition of effects: Effectiveness refers to each model’s ability to produce the expected outcomes. Effectiveness can be broken down into health and service effectiveness. Productivity refers to the relationship between services delivered and resources used to deliver them. Cost, quantity and type of resources are elements to be considered when evaluating productivity (e.g. any decrease in costs or a shift from the use of services at a specialized level to the primary health care level represents a gain in productivity, described as the substitution effect). Continuity refers to the extent to which services are offered, as a coherent succession of events in keeping with the health needs and personal context of patients. Continuity can be broken down into three components: informational continuity, relational continuity, and integrated clinical management. Accessibility covers the ease or difficulty of contacting health care services and is expressed in three ways: overall accessibility of any services; accessibility to primary health care and accessibility of other levels of care. Equity of Access indicates the extent to which the level of access meets the needs of individuals regardless off a series of factors such as age, socio-economic status or ethnic origin. Responsiveness is used to establish the extent to which services meet expectations and are deemed satisfactory by both providers and users of healthcare. Quality covers three main aspects of primary health care including: total quality as perceived by patients and professionals; technical quality, which is linked to the degree of compliance with, established guidelines; and appropriateness which reflects the suitability of the services provided.


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5.1.1a The Professional Contact Model

Strengths Accessible Responsive to patients

Weaknesses X Effectiveness X Productivity (cost & use) X Equity X Quality X Continuity

One type of professional health care model is the contact model. It aims to ensure accessibility of primary healthcare. However, care is provided almost exclusively to people who arrive at a physician’s office, by family practitioners practicing alone or in groups and more than likely to be paid on a fee-for-service basis. Rarely are practitioners associated with other healthcare professionals such as nurses. There is no formal mechanism to guarantee longitudinal continuity of care for individuals aside from patient loyalty to a physician. Within this model, there are no formal mechanisms to guarantee integration of services with other components of the healthcare system aside from certain informal arrangements such as directing patients to other sources of care or affiliated physicians. Examples of the model in Canada include private practices and walk-in medical clinics that serve as the patient’s gateway to the healthcare system. Despite the emergence of many models in Canada, this is the dominant model. The organization of primary health care in the United States and Belgium is also based on this model. 5.1.1b The Professional Co-ordination Model

Strengths Accessible Responsive to patients Productivity –

use/substitution effect Weaknesses X Effectiveness

X Equity X Quality X Productivity - cost X Continuity

A second type of professional health care model is the professional co-ordination model. The goal behind this model is to provide continuous services, overtime, primarily to patients who register with an organization to receive care. The following characteristics define this model:


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Care is provided by a team, consisting of physicians and nurses. The physician is usually designated to provide follow-up and continuity of services to

each patient. Nurses usually liaise with other components of the system and coordinate clinical

integration of services on behalf of clients. Coordination is also maintained by information technology that supports the transfer of

clinical information to other units in the health care system. Primary health care is integrated into other components of the health care system It is funded by payments to physicians, paid primarily through per capita or mixed

payment mechanisms (per-capita, sessional fees and fee-for-services)

This model is fairly uncommon in Canada, in its purest form. Health Service Organizations in Ontario are the closest example. Family physicians in England follow this model especially since the introduction of fund-holding. It is also used in Denmark, the Netherlands and the United States as part of integrated healthcare organizations known as HMOs (staff-centered model). 5.1.2 Community Primary Healthcare Models Community primary healthcare models are designed to improve the health of populations living in a given geographic area and to promote development of the communities served. They aim to meet the healthcare needs of a population and to provide it with all medical, health, social and community services required. One such mechanism for achieving broad goals is through healthcare service centers. Often, funding for centers is obtained from a local or regional health authority in one lump sum. Care is delivered by a team of professionals from various disciplines, providing a range of medical, social and community services. The community approach can be divided into two models: the integrated community model and the non-integrated community model. In Canada, the organization of primary health care is also based on community models with more than 250 healthcare centers, which vary greatly from province to province. The most striking example is that of the CLSC (local community healthcare centers) in Quebec. However, it is unclear how CLSCs differ from each other in terms of degree of integration with the rest of the health care system. It appears that CLSCs tent to follow the integrated community model in rural settings, whereas in urban areas, most CLSCs are closer to the non-integrated community model. Internationally, healthcare centers in the Scandinavian countries and primary care trusts in the United Kingdom constitute integrated community models.


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5.1.2a The integrated community model

Strengths Productivity (cost & use) Equitable access to

primary healthcare services

Effectiveness Continuity of care Quality

Weaknesses X Accessibility X Responsiveness of care

This model is premised on cooperation and interaction with the community. Services are available 24 hours a day, seven days a week, including direct patient intervention by a professional. Responsibility and longitudinal continuity is assumed by the care giving team. There is often a high degree of cooperation with other primary healthcare providers or complementary services such as hospitals, further guaranteeing service availability and range of services. The model promotes the creation of networks by using information technology that conveys clinical information within healthcare centers and to other services providers serving the same population. 5.1.2b The non-integrated community model

Strengths Productivity (cost) Equitable access to

primary healthcare services

Effectiveness Continuity of care Quality

Weaknesses X Accessibility X Responsiveness of care X Productivity (use)

The non-integrated community differs from the integrated model by the lack of specific integration mechanisms. It has the following characteristics:

The model offers the public as broad a range of services as the integrated model, but the healthcare centers provide these services directly with no collaborative arrangements with other parts of the healthcare system and no use of information technology


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This model is noted for its inaccessibility (i.e., not being available 24 hours a day, 7

days a week), lack of continuity of services to clients and poor levels of integration with services and providers in the larger healthcare system.

The CHSRF’s analysis shows that regardless of the model selected, there will always be residual areas where performance is lacking (CHSRF, 2003). While the integrated community model and the professional coordination model shows greater potential for achieving all of the desired effects of primary health care models, choosing any model involves more than an analysis of effectiveness, it requires an analysis of the nature and pace of change and potential change strategies that best respond to the local environment. The CHSRF noted that any process for converting to different primary health care models requires consideration of:

The nature of change: how radical the proposed model is from existing models and values.

The pace of change: fast or slow depending on circumstances and a timeframe that permits experimentation and learning.

Participation in change: imposed by a political or bureaucratic authority; clear direction by government; participatory change (bottom-up direction with strong professional and population-based commitment); a combination of both top-down and bottom-up direction.


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6.0 Obstacles and Barriers to Reform Implementation This literature review has served as a vital component in highlighting best practice trends and alerting the Halton-Peel Primary Healthcare Task Force to the reality of reform, including how to avoid potential roadblocks as ideas generate momentum in Halton-Peel. There are six significant “recurring weaknesses” in primary health care implementation, which present barriers or obstacles to local reform including: 1) a lack of political commitment and leadership, and insufficient policy continuity as a result; 2) temptation by government to micro-manage; 3) powerful interest groups within and outside the health system who are resistant to change; 4) failure to integrate primary health care into the overall health and social systems; 5) unrealistic objectives and expectations; 6) Failure to adopt a change strategy that matches the local environment and combines top-down policy directives with bottom-up direction (Mable and Marriott, 2000; WHO, 2003; CHSRF, 2003). A lack of political commitment and leadership, and insufficient policy continuity as a result Along with a lack of political commitment and leadership follows political indecision, ‘second-guessing”, directional shifts, inadequate resources and idling, which are all common examples of impediments to reform (Marriot & Mable, 2000; WHO, 2003). As a result, delays and reduced momentum in progress are likely to occur. Micromanagement In environments where government supports primary healthcare reform, there is often a fine line between policy supporting reform and policies that run contrary (Marriot & Mable, 2000). This temptation of governments to micro-manage can impede and frustrate organizations and agencies trying to work within imposed frameworks and rules. Interest groups Powerful interest groups (i.e., physicians) who are resistant to change represent a potentially significant barrier to primary health care reform. Most often, tension and a lack of clarity between professional groups impedes progress in multidisciplinary options (Marriot & Mable, 2000). Further complicating situations is often a lack of information systems that are able to produce reliable and effective information to support progress in collaboration and coordination of services. Failure to integrate primary health care into the overall health and social systems. To be successful in improving health outcomes, primary health care must play a role in broader policy agendas, as a cornerstone of health policy and an important component of wider social policy. At the same time, the challenge is to identify the role that primary health care should play in this broader policy agenda (WHO, 2003). Another aspect of integration is developing mechanisms that link primary health care with secondary and


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tertiary care as well as mechanisms that foster collaborative practice and an intersectoral approach. Unrealistic objectives and expectations Often initial objectives are unrealistic in that too many issues are tackled simultaneously. Primary health care cannot solve the entire problem. Consequently clear milestones need to be defined with longer-term objectives in place. Failure to adopt a change strategy that matches the local environment and combines top-down policy directives with bottom-up direction. Changing primary health care models requires an analysis of the nature and pace of change in terms of what’s feasible given the current environment, and the adoption of change strategies that best respond to the local environment. Reliance solely on top-down directions from political or bureaucratic authorities or bottom-up initiatives tends to be insufficient.


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7.0 Facilitators of Successful Reform The previous section described recurring weaknesses, which act as barriers to local reform and alluded to potential solutions. This section clarifies facilitators of successful reform based on international experience. Ten key facilitators of successful reform include (Mable & Mariott, 2000; WHO, 2003):

1. Decisive direction and commitment by government (at various levels) that is supported in several ways including: a) clearly defined milestones with longer-term objectives, b) incremental steps, c) acknowledgment of change potential, d) change management support, e) reasonable timeframes for implementation (e.g. 1-2 years), f) the widest possible stakeholder commitment to new solutions coupled with autonomy that allows stakeholders to influence the system and facilitate continuity and sustainability, and g) ongoing evaluation.

2. Tolerance for pluralism by government in terms of respect for, and allowance of, a

variety models or approaches including those that fall outside the desired framework.

3. Targeted and adequate funding to support change.

4. Physician support, but not necessarily all at the beginning.

5. Administrative simplicity.

6. Collaborative education, skill development and practice that are focused on shared-

care, inter/multidisciplinary teams of health professionals and intersectoral approaches, leading to greater integration and patient benefits.

7. Government initiatives to develop national standards regarding the terminology and

scope of practice for nurses and other non-physician health providers.

8. Electronic health information systems/technology to establish connectivity among providers along the continuum of care.

9. Public education and involvement in reforms.

10. Development of community capacity and involvement through leadership

development and devolving authority.


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8.0 Conclusion This report has tried to pull those key learning’s out from selected sources and distill them in a way that is relevant to local reform efforts. In practice, it is often difficult for one jurisdiction to take elements from a successful primary health care model and make it come to life in a different setting, as conditions vary significantly. Learning from different models however, can more easily transcend jurisdictions. When the evidence or experience from other arenas is combined with locally based research and evaluation of any changes, this improves the chances of success. Many important lessons have been learned in other jurisdictions as they have experimented with and undergone primary healthcare reform. The key to developing appropriate strategies locally is to understand the nature and pace of primary health care reform. Given a history of challenges in implementing change within primary health care reforms, understanding the nature and pace of change, clear direction with realistic milestones and longer-term objectives, as well as time-frame for experimentation and refinement, educating, supporting and promoting change, rather than ‘selling’ specific models, are key steps towards successful reform (Marriot & Mable, 2000). There is no perfect implementation process. Reform often emerges from continuous, sometimes overlapping strategies at various levels and from attempts by different stakeholders to influence system directions, sometimes in response to each other. Therefore, a system that is framed by decisive direction, but allows for autonomy and influence and incremental steps tends to motivate refinement overtime and engages the widest possible stakeholder commitment to new solutions has the greatest change of sustainable change (Marriot & Mable, 2000; WHO, 2003). Countries that support a pluralistic system through a variety of model options, embrace a tolerance for pluralism and hold respect for models that fall outside of the desired framework achieve the most success. This approach creates an environment where there is opportunity for a continuum of change to take place ranging from convergent to radical. It requires that government policy accept pre-existing and new models as an interim or permanent approach, exhibit a willingness to let things evolve, rather than micro managing the process and, quickly provide long-term commitments to implementation and ongoing refinement of existing models. (Marriot & Mable, 2000).


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References Canadian Health Services Research Foundation (CHSRF). 2003.Choices for Change: The Path for Restructuring Primary Healthcare Services in Canada.

Canadian Institute for Health Information, 2003. Health Care in Canada.

Hutchison, B. Abelson J. & Lavis, J. Primary Care in Canada: so much innovation, so little change. Health Affairs 1002; 20 (3): 116-31.

Mable, A. and Marriott, J. (2002). Sharing The Learning – The Health Transition Fund Synthesis Series: Primary Health Care. Minister of Public Works and Government Services Canada.

Marriott, J. and Mable, A. August 2000. Opportunities and Potential – a Review of International Literature on Primary Heath Care Reform and Models. Prepared for Health Human Resource Strategies Division, Health Policy and Communications Branch Health Canada. Minister of Public Works and Government Services Canada. Marriott, J and Mable, A. Comparing and Contrasting Primary Health Care Reform. Presentation at Insight’s 5th Annual Forum Primary Health Care in Canada, September 18-19, 2003 Metropolitan Hotel. Macinko, J., Starfield, B., & Shi, L. June 2003. The Contribution of Primary Care Systems to Health Outcomes within Organization for Economic Cooperation and Development (OECD) Countries, 1970-1998. HSR: Health Servcies Research 38.3, pp. 831-865.

PriceWaterhouseCoopers, March 31, 2001. Report to the Health Transition Fund on the Evaluation of Primary Care Reform in Ontario. World Health Organization. October 2003. Primary Health Care: A Framework for Future Strategic Directions. (Updated Draft Report)


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Appendix A Definitions of Primary Health Care The “WHO” Definition of Primary Health Care “Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and by means acceptable to them and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part of both the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family, and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.”

World Health Organization, 1978

The HSRC Definition of Primary Health Care In 1999 the Ontario Health Services Restructuring Commission provided a definition which brought together the WHO’s definition and the PCCCAR’s list of core services. The HSRC defined primary health care as: “Primary health care is the first level of care, and usually the first point of contact, that people have with the health care system. Primary health care supports individuals and families to make the best decisions for their health. It includes advice on health promotion and disease prevention, health assessments of one’s health, diagnosis and treatment of episodic and chronic conditions, and supportive and rehabilitative care. Services are coordinated, accessible to all consumers, and are provided by health care professionals who have the right skills to meet the needs of individuals and the communities being served. These professionals work in partnership with consumers, and facilitate their use of other health-related services, when required.”

Health Services Restructuring Commission (HSRC), 1999

Starfield’s Definition and Attributes of Primary Health Care Barbara Starfield from the School of Hygiene and Public Health at John Hopkins University suggested that primary health care is the linking together of services that: • Promote and preserve health • Prevent disease, injury, and dysfunction


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• Provide care of acute and chronic conditions as well as handicaps, impairment, and

disabilities • Serve as an ongoing source of person-oriented care over time • Is planned and implemented using knowledge about the families, communities, and

cultures of the population served. In addition, the attributes of primary health care include: • First contact care: Involves the provision of services are accessible and the utilization of

those services when a need for care arises. First contact refers to the primary care provider being responsible for assisting the client to enter the health care system for each non-referred provision of health care.

• Longitudinal or Ongoing Care: involves the use of a regular source of care overtime that

is not limited to certain types of health needs. It involves the development of a patient-provider relationship based on established trust and knowledge of the patient and his/her family. A “health care home” is thus established for each patient to promote the provision of ongoing care regardless of the presence or absence of disease.

• Coordination is linking of health care events and services. It requires the establishment

of mechanisms to communicate information and the incorporation of that information into the client’s plan of care. Primary health care has the responsibility and obligation to transfer information to and receive it from other resources that may be involved in the care of a client, and to develop and implement an appropriate plan for health care management and disease prevention.

• Community oriented care refers to efforts to recognize the primary health care needs of

a defined population. The effective delivery of services to individuals and communities is based on an understanding of community needs and the integration of a population perspective in the provision of health care. Primary health care providers contribute to and participate in community assessment, health surveillance, monitoring, and evaluation.

• Culturally competent care incorporates cultural references into the provision of primary

care. Services are designed to be acceptable to people in the community, who may be distinguished by common values, language, heritage, and beliefs about health and disease. The views of these groups should be determined and incorporated into decisions involving policies, priorities, and plans related to the delivery of health care services.

Barbara Starfield, 1998

overview of selected primary health care models · overview of selected primary health care models...

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